C L I N I C A L
P R A C T I C E
Developing a
Therapy Bed
Assessment Tool
BY
Kathryn Kozell
Kathryn Kozell,
RN, BA, BScN, MScN,
ACNP/ET, is an Acute
Care Nurse Practitioner/
Clinical Nurse Specialist
in surgery at St. Joseph’s
Health Care London in
Ontario. She has been
an Enterostomal Therapy
Nurse since 1981. She
is also a member of the
CAET and CAWC.
12
Wo u n d C a re C a n a d a
T
herapeutic mattresses and bed frames are
Therapy Bed Task Force
designed to provide either pressure reduc-
Our facility established the Therapy Bed Task Force, a
tion or pressure relief in situations where
nursing initiative that was composed of various clinicians
skin integrity or other physiological systems are in
representing the intensive care unit, orthopedics, family
jeopardy of potential or actual injury. One of the greatest
medicine and palliative care, as well as an acute care
challenges for the clinician is to select the most appropri-
nurse practitioner/clinical nurse specialist/enterostomal
ate product for a patient’s specific individual demands.
therapy nurse in surgery, a purchasing representative
The experience of St. Joseph’s Health Care London, in
from materials management, and a territory sales man-
identifying the multiple risk needs of patients, institu-
ager from the contracted company from which the ther-
tional requirements and using an interdisciplinary team
apy beds were being rented. The mandate of this team
approach for developing a therapy bed assessment tool
was threefold: 1. investigate and identify the pattern
may serve as a useful model for other facilities.
of therapy bed utilization within the health centre;
There is a heightened awareness among health-care
2. develop and implement a system that would monitor
professionals to seek out the best possible products
and provide consistent and effective therapy bed
that will provide the most efficient and effective thera-
utilization; and 3. control the financial allowance
peutic response. This has been well demonstrated with
dedicated to therapy bed rental.
the vast selection of wound-care products available to
Doughty, Fairchild and Stogis2 referred to a three-phase
meet the specificity of any wound. In the treatment of
decisional approach regarding the use of replacement
pressure-related skin injuries, specialty beds, perhaps
mattresses. Using this approach in a slightly modified
surprisingly, are not a new supportive device. In A
process, our team concluded it was important to
Historical Perspective on Specialty Beds and Other
determine the following:
Apparatus for Treatment of Invalids1 a medical report
1. who was using the therapy bed
from way back in 1585 cites the “successful use of a
2. what the selection criteria were
down cushion in concert with a program of nutrition,
3. what therapy bed would then be selected for
hygiene, and pain relief for a pressure ulcer.” In today’s
implementation
world of therapeutic mattresses, manufacturers have
responded with many therapeutic pressure devices;
Results of the Task Force
however, the decision-making process leading to the
The Task Force identified that there were high-demand
appropriate selection of the right mattress for the right
therapy bed units (the intensive care unit, orthopedics
patient can be as challenging as the presentation of
and family medicine/palliative care) and low-demand
any wound.
therapy bed units (general medicine, general surgery—
Vo l u m e 2 , N u m b e r 2
TABLE 1
Clinical Diagnoses/Characteristics
patterns. This was accomplished by
References
combining patient characteristics within
1. Levine JM. A historical
perspective on specialty
beds and other apparatus
for treatment of invalids.
Advances in Wound Care.
1994;7(5):51-54.
each of the high- and low-demand
Medical
Surgical
Critical Care
Dermatitis
Flaps, grafts
Hemodynamically
unstable
found in the Braden Scale for Predicting
Oncology
Draining wounds
Comatose
health pattern category now had three
Paralysis
Sepsis
Positional
intolerance
to four descriptors, which described a
Multiple ulcers
Multiple ulcers
Sepsis
functional health demands to very
Multiple fractures
secondary to pathology
Multiple bone fractures
Large abdominal
wounds
complex functional health demands).
units with the clinical descriptors as
Pressure Sore Risk.4 Each functional
range of health demands (from free of
A score of zero (no risk) to eight
(multiple risks) was assigned to each of
Failed grafts
the health responses.
The territory sales representative
primarily the vascular population). Once the patient-
of the bed company contracted to our region was
care areas were recognized, it was then critical to
instrumental in providing the task force with information
determine and analyze the patient demand, (essentially,
about each of the therapy mattresses available. The
what diagnoses or health-care patterns were patients
clinical data to support their function, anticipated
presenting that warranted a therapy bed?). Table 1
outcome and specific features given the health demand
identifies the patient clinical characteristics for each of
of the patient were reviewed and incorporated into the
the high/low demand areas.
tool. An assessment score was developed that further
2. Doughty D, et al. Your
patient: Which therapy?
Journal of Enterostomal
Therapy. 1990;17(4):
154-159.
3. Gordon M. Nursing
Diagnosis: A Process and
Application. McGraw-Hill.
1982.
4. Bergstrom N, et al. The
Braden scale for predicting
pressure score risk. Nursing
Research. 1987;36(4):
205-210.
identified the type of therapy bed for the score range.
Documentation Development
Continued on page 14
During this period, the health centre’s nursing documentation was undergoing redesign to reflect Marjorie
TABLE 2
Gordon’s Functional Health Patterns.3 The typology of
the functional health patterns provides an assessment
Modified Gordon’s
Functional Health Patterns
framework for identifying a patient’s health pattern
(with sixth and seventh categories added)
profile. To be consistent with both the documentation
policy of the health centre and the overall nursing documentation system, the Therapy Bed Task Force adapted
Health–perception–health management
patterns
Nutritional–metabolic pattern
five of Gordon’s 11 functional health patterns as the
Elimination pattern
overall framework for the assessment tool (see Table 2).
Activity–exercise pattern
The task force added a sixth and seventh health pattern,
Sleep–rest pattern
Mobility-Exercise and Integumentary. Integumentary
Self perception–self-concept pattern
was specifically added, rationalizing that the skin, as the
Role–relationship pattern
largest organ—being multifunctional and subjected to
varying degrees of threat and injury—was deserving of its
own category.
The creative aspect of developing the therapy bed
assessment tool came with identifying the range of
Sexuality–reproductive pattern
Coping–stress-tolerance pattern
Value–belief pattern
Cognitive–perceptual pattern
Mobility–exercise
Integumentary
“health responses” within each of the assessment health
Vo l u m e 2 , N u m b e r 2
Wo u n d C a re C a n a d a
13
Upon completion of the assessment
TABLE 3
tool, the clinician calculates a total
Therapy Bed Assessment Tool (TBAT)
PO #
Date Bed Received:
Assessment
0–5
6–10
11–15
Room #
Ht.:
score, which provides a recommendWt.:
Recommended Bed Type
Not Recommended – Conservative
First Step Select
Therakair
Max. 200 lbs. ambulatory, pressure relief, edema, pulsation mattress
Kinair
Max. 300 lbs., non-ambulatory, advanced pressure relief, no pulsation
16–20
Therapulse
Max. 300 lbs., non-ambulatory, advanced pressure relief, edema, pulsation
ICU only
Biodyne
Max. 300 lbs., rotation, wider bed, deeper cushion, advanced therapy relief
Triadyne
Kinetic rotation, percussion, vibration, pulsation, pressure relief
Safety/Management Barikair
Wt: 350–850 lbs.
Date
Risk Factor Assessment
Score Wk. 1 Wk. 2 Wk. 3
Health Management Pattern
Free of major non-active health problems
0
Intractable pain, grafts, myocutaneous flaps
1
PVD, failed grafts/flaps, edematous, septic, fractures
2
Hemodynamically unstable, chest trauma, CVA, neurological
conditions, ventilatory instability
3
Activity-Exercise Pattern
Ambulatory without assistance
0
Up in a chair, confined to chair/wheelchair
1
Bed rest
2
Mobility-Exercise Pattern
Independently moves extremities
0
Two turning surfaces available
1
One turning surface available
2
Immobile
3
Elimination Pattern
Full bowel/bladder control, no diaphoresis
0
Either bowel/bladder incontinence, or diaphoresis
1
Bowel and bladder incontinence, no diaphoresis
2
Bowel and bladder incontinence and diaphoresis
3
Integumentary
No skin breakdown
0
Stage I—Epidermis intact, reddened
2
Stage II—Blistered, epidermis break, more than two ulcers,
moderate to large draining wounds
4
Stage III and IV—Ulceration to tendon, bone, muscle
8
Nutritional-Metabolic Pattern
Nourished—adequate food/fluid intake, weight stable
0
Malnourished—limited oral intake, dehydrated, obese,
cachectic, IV therapy, enteral supplements
1
Supplemented—no oral intake, TPN
2
Cognitive Pattern
Alert, oriented x 3
0
Confused, disoriented, responds to visual, verbal, pain stimuli
2
Comatose (no visual, verbal, pain response)
3
Total Score
Nurse’s Initials
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Wo u n d C a re C a n a d a
ation for the type of therapy bed appropriate for the patient being assessed
(see Table 3).
Therapy Bed Assessment Tool
Development
The outcome was a Therapy Bed
Assessment Tool, which is designed to
guide the clinician through a systematic
process of assessing the patient
through each of the seven functional
health patterns. The operational word
here is “recommended.” The clinician
must still use his or her judgment to
match the needs of the patient with
the recommendation, always leaning
toward maximizing the patient’s potential with the therapy bed and supporting
those areas the patient and staff cannot
meet together.
There are certainly limitations to this
tool, as it was designed with the acutecare perspective only and it has never
been put through the rigours of being
tested for reliability or validity. However,
it has reinforced that the prescriptive
nature of a therapy bed shows that it is
not “a luxury item” but is an important
and necessary variable in the overall
treatment plan, which is grounded in
science and research.
Note to readers: The printing of brand
names in the assessment tool does not
in any way indicate an endorsement by
the Canadian Association of Wound
Care or Wound Care Canada for any
of the products listed. Brand name
inclusion was permitted to preserve the
original intent of the tool.
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